Clinical Analyst (US Registered Nurse (RN) or Licensed Vocational

ROLE SUMMARY

Our client is looking for a Clinical Analyst who will be responsible for the review and assessment of clinical denials, including review of patient medical information, patient account documents, patient account history, historical data, provider contracts, and regulations as appropriate. The Clinical Analyst will support and ensure the performance, productivity, efficiency, and profitability of the organization through accurately reviewing, validating, and where appropriate liquidating inventory.

The Clinical Analyst will draft focused, successful appeals, meet, and confer documents, and IRO submissions, and when necessary, assist with legal submissions on clinical issues and communicate with hospital case management personnel to confirm facts, solicit needed information, and assist in managing the clinical review program. The Clinical Analyst will provide support to legal staff on patient accounts and presentation of matters needed and assist with building the clinical review program.

SCHEDULE: 8:00 AM – 5:00 PM Pacific Daylight Time (11:00 PM – 8:00 AM Philippine Standard Time), follows Philippine holidays

POSITION TYPE: Full Time

WORK ARRANGEMENT: Remote

ESSENTIAL FUNCTIONS

Prioritize voluminous claim review workload

Recruit and coordinate the training of the clinical review team

Design and implement strategies for the clinical review team to meet the firm goals and objectives

Manage the clinical review team staff by assigning and delegating tasks as needed

Develop policies and procedures to ensure the clinical review team's productivity

Ensure all policies and procedures function per state and federal laws

Serve as a liaison between clients and the firm

Prioritize voluminous claim review workload

Validate claim status, claim liability, and availability of coverage

Understand concepts of coverage, contract interpretation, and reimbursement methodologies needed to analyze claims

Draft appeals, meet and confer documents, to resolve/overturn the clinical denial of patient accounts

Prepare and submit IRO submissions when mandated by the contract

Demonstrate understanding of relationships between health plans and providers

Research and analyze information including employing advanced health care analytics and data science techniques to diagnose reimbursement issues, opportunities assessment, claim trends, develop solutions, and initiate appropriate claim resolution strategies on accounts with clinical denial issues

Maintain quality and productivity standards as set by management

Influence others using a positive approach

Perform special projects as requested

Ensure compliance with the Health Insurance Portability and Accountability Act

Follow any other job-related instructions and perform any other job-related duties requested by the supervisor

QUALIFICATIONS

A bachelor’s degree in the related field

Registered Nurse (RN) or Licensed Vocational Nurse license

3-5 years of position-specific related work experience (managed care, revenue cycle, data mining, and/or legal)

3-5 years of experience working on hospital claims

5+ years of utilization/case management experience

Experience with healthcare provider claims management software is highly preferred

Experience in a multi-client environment

Experience and an appetite for analytics and quantitative/qualitative/data analysis

Possess strong analytic and technical skills plus an ability to translate complicated data into useable information

Strong computer aptitude, which includes expertise with Microsoft 365 applications

Strong organization, oral and written communication skills

Analytical skills with particular attention to detail

Ability to function in an autonomous environment—independent worker, self-directed

What awaits you upon securing the position?

Attractive compensation

Assured allowances

Leave credits

Overtime Pay

Night differential benefits

Comprehensive health and life insurance upon hiring, covering one free dependent

Special anniversary incentives

13th-month salary bonus

We provide the necessary equipment!

Other Details

Work Schedule: Night Shift

Full Time

Permanent WFH set-up

Summary of role requirements:

Looking for candidates available to work:

Monday: Evening

Tuesday: Evening

Wednesday: Evening

Thursday: Evening

Friday: Evening

More than 4 years of relevant work experience required for this role

Working rights required for this role

Full time